17y · Female·Acute Lymphocytic Meningitis and Focal Myocarditis
…ary 2009 on oral analgesia with instructions to follow up with her GP. On 10 January 2009, she suffered a cardiac arrest at home and was transferred to ICU where she died. Post-mortem revealed acute lymphocytic viral me…
24y · Male·methamphetamine toxicity in the background of atrioventricular node artery dyspl…
…nd appropriate; no physical contact or improper conduct occurred. The primary clinical issue was that his cardiac structural abnormality, combined with stimulant use and the physiological stress of police pursuit, creat…
69y · Male·Ischaemic cardiomyopathy due to or as a consequence of coronary atherosclerosis …
…gy review, close glucose monitoring, and appropriate management of his multiple comorbidities. His severe cardiac disease placed him at high risk of fatal arrhythmia and myocardial infarction. The coroner concluded his …
2y · Male·Myocarditis secondary to Kawasaki Disease
…ypical features that are actually characteristic of acute-phase KD. He deteriorated at home and suffered a fatal cardiac arrhythmia due to myocarditis secondary to KD on 9 September. Expert reviewers confirmed KD was di…
42y · Male·Ischaemic heart disease and methylamphetamine intoxication
…he toxic range, plus cannabis. The coroner concluded death resulted from Mr White deliberately injecting a fatal quantity of methylamphetamine while already having significant underlying coronary disease. The death was …
51y · Male·Combined effects of atherosclerotic cardiovascular disease and seizure activity …
…evel of caffeine (64mg/L, equivalent to approximately 2000mg or 20 espresso coffees), which precipitated a fatal cardiac event in the context of critical coronary artery stenosis (90% occlusion of left anterior descendi…
20y · Male·Electrocution resulting in cardiac arrhythmia and cardiac arrest
…d that had been raised to 8 metres. The scaffold came into contact with overhead power lines, resulting in fatal electrocution. Multiple preventable factors were identified: the scaffold exceeded safe height-to-base rat…
27y · Male·propoxyphene toxicity
A 27-year-old man with schizophrenia died of propoxyphene toxicity while in police custody. He ingested a fatal dose of Doloxene capsules prescribed by Dr R. on 27 June 2000. The doctor prescribed 100 capsules to a pat…
41y · Male·Cardiomegaly in a man with WHO Class III obesity
…om 82kg to 175kg. While obesity itself was not the direct cause, it created conditions predisposing him to fatal cardiac arrhythmia. Clinical care in the days before death was adequate, but systemic failures included: n…
67y · Male·Ischaemic Heart Disease and Coronary Artery Atherosclerosis
…is died from ischaemic heart disease. While exertion and stress from being lost may have contributed to a cardiac event, this could not be definitively established. Key failures included: failure to formally reassess an…
58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis
…exertional chest pain and shortness of breath. He was diagnosed with stable angina and discharged home on cardiac medications. He returned the next day with dizziness attributed to beta-blocker side effects and was agai…
82y · Male·Ischaemic heart disease due to coronary atherosclerosis with significant contrib…
…maintain constant electronic monitoring during a critical period, and delayed CPR by 15 minutes. While the fatal cardiac event could not have been predicted, expert evidence suggests earlier hospital transfer might have…
43y · Female·acute toxic effects of amitriptyline
… not checked until 7.33 AM when she was found unresponsive. Autopsy confirmed amitriptyline toxicity with cardiac scarring. Key failings: premature discharge without complete cardiac investigation, inadequate assessment…
47y · Female·acute subendocardial septal myocardial infarction complicating hypertension and …
A 47-year-old woman with hypertension, high cholesterol, and significant family history of early cardiac disease presented to a country hospital ED with acute crushing central chest pain (10/10), shortness of b…
50y · Male·bronchitis (pandemic influenza A/H1N1 2009) in a man with chronic obstructive pu…
…d not be revived. Postmortem examination confirmed influenza A/H1N1 bronchitis with underlying COPD as the fatal combination. The coroner found the supervision, treatment and care provided was reasonable and appropriate…
61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…
…al leak was likely contained for three days post-operatively before bursting on day three, causing sudden cardiac arrest and fatal hypoxic brain injury. Clinical lessons include: difficulty detecting post-operative dete…
58y · Male·coronary artery arteriosclerosis (natural causes)
…itated at BMHU, making examination unsafe; antipsychotic medications were necessary and not excessive. The fatal cardiac disease remained undetected as he refused assessment and complained of no cardiac symptoms. Clinic…
36y · Male·Acute on Chronic Myocardial Infarction
Mark Anselo Ugle, a 36-year-old Aboriginal man with a significant history of cardiac problems, seizures, and non-compliance with medication, died in East Perth Lockup on 9 December 2000 from…
73y · Male·ischaemic heart disease due to coronary atherosclerosis
…multiple falls, grappling holds, and apparent bear-hug and full-Nelson manoeuvres, the man collapsed with cardiac arrest within minutes. He had severe coronary atherosclerosis with multiple blocked coronary vessels and …
60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…
…on 2 November 2005. The 14mm perforation created catastrophic bleeding into the pericardial space causing cardiac tamponade. Although the procedure was appropriately indicated for an infected pacemaker and performed by …
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